Introduction to Dentistry Unit VII Charting & Diagnostic Aids
The Dental Exam Methods investigating oral cavity Palpation Percussion Visual X-rays
The Dental Exam The Clinical Oral Exam buccal mucosa gingiva tongue + floor of mouth palate uvula occlusion - centric
The Dental Exam soft tissues of oropharynx saliva - consistency and quantity breath tongue or sinus mucobuccal folds vestibule
The Dental Exam Extra Oral Exam speech facial configuration lymph nodes - swelling or tenderness TMJ oral habits - bruxing, thumb sucking, mouth breathing lips - texture, color, deviations from norm
The Dental Exam Diagnostic Aids X-rays Study models Photos Intraoral imaging Intraoral photography Pamphlets, bulletins or actual items (ie: crown) Models of: implants, partial, dentures etc.
The Dental Exam Intraoral Imaging patient ed & dx tool explain procedure verification for insurance
The Dental Exam Intraoral Imaging Consists of 4 parts: handpiece = capture image computer = process & store monitor = project image color printer = print image
The Dental Exam Intraoral Photography record before, after record major restorative tx esthetic restorations full face, profile images cheek/lip retractors people forget marketing tool
Clinical Records Charting records regarding pt info pt tx accurate & complete in INK
Clinical Records Oral System dentist dictates assistant records on hard copy use colored pencils
Clinical Records Computerized System voice activated dentist wears microphone dictates information computer generates color coded printout
Clinical Records Financial Arrangements chart is an estimate proposed tx/fee date & sign patient & office copy
Cardinal Rules 1. accurately chart errors result in scheduling/tx errors 2. only red/blue pencil 3. learn your dentists system 4. pay attention, listen carefully 5. ask to repeat
Types of Charting Systems Palmer FDI Universal
Current Conditions Red NEEDS to be done Blue existing restorations/conditions
Current Conditions Super Numerary = Mesioden = Periapical Abscess = Fractured Tooth = Fractured Restorations = Recurrent decay =
Current Conditions Teeth to be extracted = Impacted = Direction = Space Closed = Tooth Rotated =
Common Charting Conditions Amalgam fill in completely Composite outside line Fixed Prosthetics single crowns, a bridge or implant
Common Charting Conditions Removable Prosthetics PUD/PLD or FUD/FLD or CUD/CLD Root Canal Therapy Needs or completed
Common Charting Conditions Broken/Cracked Filling= Temporary Fillings = Build Ups= Sealants =
Periodontal Screening and Records - PSR System detect periodontal disease determine pt needs periodontal exam
Periodontal Screening and Records - PSR Overall Gingival Health Color: pink vs. red Firmness: tight/stippled vs boggy/puffy Serum: clear vs. blood or exudate
Periodontal Screening and Records - PSR Periodontal Probing healthy = 1-3 mm gingival recession = red line at CEJ periodontal pocket = 4+
Periodontal Screening and Records - PSR Furcation Involvement I II III
Periodontal Screening and Records - PSR Mobility I = slight II = moderate III = extreme
Orthodontia Occlusion classification Needed tx Current tx name of orthodontist how long fixed or removable
Pathology Record : any abnormal findings head/neck intraoral cancer screening vestibule, cheeks/lips tongue/palate
Pulp Vitality Record vitalometer readings response to hot/cold percussion or pain color & sound needs or has had RCT